Preferred choice

This is a preferred choice antidepressant due to low levels in breast milk and favourable drug properties.

Infant monitoring

As a precaution, monitor for irritability, restlessness, drowsiness, constipation, poor feeding and adequate weight-gain.

Further information

Significant published evidence shows that paroxetine passes into breast milk in very small amounts (ranging from 0.1%–4.3% of the weight-adjusted maternal dose) with maternal doses up to 60mg daily.

In one study, paroxetine was detected in infant serum as 5% of the maternal serum level. In other studies paroxetine has not been detectable in infant serum.

In most cases short or longer-term infant side-effects have not been reported. However, there have been occasional reports of irritability, insomnia, restlessness, poor feeding, sedation and constipation. A single case of severe hyponatraemia has been described, although causality was not proven. Side-effects are reported more often when paroxetine is also taken during pregnancy.

Preferred choice

This is a preferred choice antidepressant due to low levels in breast milk and favourable drug properties.

Infant monitoring

As a precaution, monitor for agitation, restlessness, insomnia, drowsiness or other sleep disturbances, diarrhoea, poor feeding and adequate weight-gain.

Further information

Significant published evidence shows sertraline passes into breast milk in very small amounts (0.2–2.4% of the weight-adjusted maternal dose) with maternal doses up to 200mg daily. In many cases, the amount in breast milk was negligible. One study found no correlation between dose and milk levels.

Levels of sertraline (or the active metabolite norsertraline) in infant serum are very small (on average 2% of maternal serum levels for sertraline) or undetectable with maternal doses up to 200mg. In a few cases, the infant serum level was reported as greater than 10%.

Generally, infant side-effects have not been reported. Six-month follow-up studies show normal weight gain and neurological development.

There have been occasional reports of jitteriness, restlessness, agitation, poor feeding, diarrhoea, sleep disturbances, insomnia, and sedation. One case reported toxicity in a preterm infant (hyperthermia, effects on muscle tone, tremor, shivering and irritability); the mother had been taking 150mg sertraline during pregnancy and the infant was found to have genetically reduced sertraline metabolism.

Despite sertraline being a known inhibitor of platelet function, no such effects have been detected in infants exposed via breast milk.

Use with Caution

Citalopram can be used with caution during breastfeeding, but sertraline or paroxetine are preferred.

Infant monitoring

As a precaution, monitor for irritability, restlessness, drowsiness, colic, poor feeding and adequate weight-gain.

Further information

Most evidence shows that citalopram passes into breast milk in negligible or small amounts (0.7–7.9% of the weight-adjusted maternal dose) with maternal doses up to 80mg daily. However, there have been 2 isolated cases reporting much higher levels (13.2% and 18.4% of the weight-adjust maternal dose).

Infant serum levels of citalopram are low (0.9–7% of the maternal serum level). In one isolated report the infant serum level was over 10% of the maternal serum level.

Citalopram has often been used during breastfeeding without any short or longer-term infant side- effects. There have been some case reports of colic, decreased feeding, irritability, restlessness and drowsiness.

Use with Caution

Escitalopram can be used with caution during breastfeeding, but sertraline or paroxetine are preferred.

Infant monitoring

As a precaution, monitor for irritability, restlessness, drowsiness, vomiting, poor feeding and adequate weight-gain.

Further information

Limited evidence shows that escitalopram passes into breast milk in small amounts (2.6%–7.7% of the weight-adjusted maternal dose) with maternal doses up to 20mg daily.

Infant serum levels have been reported as very low, and in some cases undetectable. A pharmacokinetic modelling study predicts infant serum levels to be around 1.7% of maternal serum levels.

Use of escitalopram is not usually associated with any side-effects. However, there have been some reports of irritability, restlessness, drowsiness, and vomiting. One case of necrotising enterocolitis, and one of convulsions have also been reported, although the association with breastfeeding was uncertain.

Use with Caution

Fluoxetine can be used with caution. It has been used during breastfeeding for many years, but sertraline or paroxetine are preferred.

Infant monitoring

As a precaution, monitor for irritability, restlessness, drowsiness, colic, gastro-intestinal disturbances, poor feeding, and adequate weight-gain.

Further information

Significant published evidence shows that fluoxetine passes into breast milk in variable amounts (ranging from 0.54%–10.8% of the weight-adjusted maternal dose) with maternal doses of up to 80mg daily. Some single case reports describe much higher levels; up to 20% of the weight-adjusted maternal dose.

Both fluoxetine and its active metabolite norfluoxetine have been detected in infant serum in low or undetectable levels. In one study, some infants had elevated serum levels greater than 10% of the maternal level. Exposure during pregnancy was thought to influence these higher levels.

Most published reports have not identified any side-effects, including longer-term neurodevelopment. However, infant side-effects are reported more often with fluoxetine compared to other SSRIs, which may reflect wider use. The very long half-life of fluoxetine (4–6 days), and norfluoxetine (4–16 days), greatly increases the risk of accumulation in breastfed infants.

Reported side-effects include colic, decreased sleep, vomiting, watery stools, hyperactivity, and decreased weight gain. Seizure-like activity, cyanosis, hyperglycaemia and glycosuria have also been reported, although causality has not been proven.

Two case reports of fluoxetine toxicity (tachypnoea, hypotonia, difficulty in arousing, jitteriness, and low- grade fever) have been described during breastfeeding. Exposure during pregnancy was thought to contribute and all symptoms resolved when breastfeeding was discontinued.